Provider Demographics
NPI:1407895626
Name:PARK, SEON JI (MFC)
Entity Type:Individual
Prefix:
First Name:SEON
Middle Name:JI
Last Name:PARK
Suffix:
Gender:F
Credentials:MFC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12450 VAN NUYS BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1393
Mailing Address - Country:US
Mailing Address - Phone:818-896-1161
Mailing Address - Fax:818-896-5069
Practice Address - Street 1:1000 CORPORATE CENTER DR STE 650
Practice Address - Street 2:
Practice Address - City:MONTEREY PARK
Practice Address - State:CA
Practice Address - Zip Code:91754-7639
Practice Address - Country:US
Practice Address - Phone:626-966-1776
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42519106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA6758Medicaid
CA7420Medicaid